Free Therapy Application
Midsouth Mental Health is committed to making therapy accessible to those in need. Please complete this form to apply for free therapy sessions. All information is confidential. **If you are currently in crisis or experiencing thoughts of self-harm, Please call 988 for immediate support.
Name
First Name
Last Name
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Do You currently Have Health Insurance?
Please Select
Yes
No
Unsure
Are You Experiencing Financial Hardship that prevents you from paying for therapy
Please Select
Yes
No
Unsure
Briefly explain your current financial situation and why you are requesting free therapy:
What are your main reasons for seeking therapy? (Check all that apply)
Please Select
Anxiety
Depression
Grief/Loss
Relationship issues
Trauma
Life Transitions
Stress Management
Other
Agreement & SignatureBy submitting this application, I certify that the information provided is accurate. I understand that free therapy sessions are limited and that applying does not guarantee approval.
Date
-
Month
-
Day
Year
Date
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Should be Empty: